Zusammenfassung
Einleitung
Wundinfektionen nach Schilddrüsenoperationen sind überwiegend oberflächlich und gut zu therapieren. Eine Streptokokkenmediastinitis nach Thyreoidektomie stellt eine sehr seltene, jedoch lebensbedrohliche Komplikation dar.
Fallbericht
Zwei Tage nach Thyreoidektomie wegen einer Basedow-Struma trat bei einer 57-jährigen Patientin septisches Fieber, hohe Entzündungsparameter und eine inflammatorische Hautrötung im Bereich der Operationswunde auf. Ursache war eine tiefe 3-Kompartment-Infektion durch Streptokokken der Gruppe A (GAS) unter Einbeziehung des hinteren Mediastinums. Sieben Wundrevisionen in Vollnarkose, die adaptierte Antibiose und eine zervikale Unterdrucktherapie konnten die lebensbedrohliche Infektion nach 6-wöchiger Behandlungsdauer beherrschen. In der Literatur sind 21 Fälle beschrieben, davon 11 mit letalem Ausgang.
Schlussfolgerung
Hohes Fieber, Entzündungsparameter und lokale Inflammation in der frühpostoperativen Phase nach Thyreoidektomie sind Hinweise für eine GAS-Infektion. Es besteht die Gefahr einer nekrotisierenden und deszendierenden Mediastinitis mit vitaler Bedrohung. Rasche Diagnostik, CT, Etappenlavagen mit Wundabstrich, intravenöse antibiotische Therapie mit Penicillin G und Clindamycin sind dringlich geboten. Bei Therapieresistenz ist an eine zervikale Unterdrucktherapie zu denken.
Abstract
Introduction
Surgical site infections after thyroid surgery are mostly superficial and can be well treated. Streptococcal mediastinitis in contrast is a rare but life-threatening complication.
Case report
A 57-year-old female patient experienced septic fever, increase of inflammation parameters and erythema 2 days after thyroid surgery for Graves’ disease. This process was triggered by a three-compartment infection by group A Streptococcus (GAS) with involvement of the mediastinum. Therapy over 6 weeks including seven wound revisions with the patient under general anesthesia, pathogen-adapted antibiotic treatment and cervical negative pressure treatment managed to control the infection. A total of 21 cases have been published on this phenomenon, 11 of which had a fatal outcome.
Conclusion
High fever and surgical site erythema in the early postoperative period after thyroid surgery can be signs of a GAS infection, which might lead to necrotizing, descending, life-threatening mediastinitis. Early diagnosis with support of computed tomography (CT) scans, immediate therapy including wound opening, lavage, intravenous antibiotic treatment with penicillin and clindamycin are vital. If treatment resistance occurs, cervical negative pressure treatment should be considered.
Abbreviations
- ASA-Score:
-
American Society of Anesthesiologists
- CDC:
-
Centers for Disease Control and Prevention
- CFR:
-
case fatality ratio
- CNP:
-
controlled negative pressure
- CT:
-
Computertomographie
- GAS:
-
Gruppe-A-Streptokokken
- NNIS-Scores:
-
National Nosocomial Infections Surveillance System
- STSS:
-
streptococcal toxic shock syndromes
Literatur
Bures C, Klatte T (2014) Guidelines for complications after thyroid surgery: pitfalls in diagnosis and advices for continuous quality improvement. Eur Surg 46:38–47
Bures C, Klatte T (2014) A prospective study on surgical-site infections in thyroid operation. Surgery 155(4):675–681
Bures C, Bobak-Wieser R (2014) Late-onset palsy of the recurrent laryngeal nerve after thyroid surgery. Br J Surg 101(12):1556–1559
Centers for Disease Control and Prevention (CDC) (1999) Nosocomial group A streptococcal infections associated with asymptomatic health-care workers – Maryland and California, 1997. Morb Mortal Wkly Rep 48(8):163–166
Szczypa K, Sadowy E (2006) Group A streptococci from invasive-disease episodes in Poland are remarkably divergent at the molecular level. J Clin Microbiol 44(11):3975–3979
Hardy RG, Forsythe JL (2007) Uncovering a rare but critical complication following thyroid surgery: an audit across the UK and Ireland. Thyroid 17(1):63–65
Nikolaos ND, Apostolakis EE (2007) A less invasive management of post-thyroidectomy descending necrotizing mediastinitis is feasible: a case report and literature review. Med Sci Monit 13(7):CS83–CS87
Faibis F, Sapir D (2008) Severe group A streptococcus infection after thyreoidectomy: report of three cases and review. Surg Infect 9:529–531
Hermann M (2010) Schilddrüsenchirurgie. Springerverlag, Wien
Collin Y, Sirois M (2012) Group A streptococcus causing descending necrotizing mediastinitis: report of a case and literature review. Surg Infect 13:57–59
Karlik JB, Duron V (2013) Severe group a streptococcus surgical site infection after thyroid lobectomy. Surg Infect 14(2):216–220
Kaul R, McGeer A, Norrby-Teglund A (1999) Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome – a comparative observational study. The Canadian Streptococcal Study Group. Clin Infect Dis 28(4):800–807
Norrby-Teglund A, Ihendyane N (2003) Intravenous immunoglobulin adjunctive therapy in sepsis, with special emphasis on severe invasive group A streptococcal infections. Scand J Infect Dis 35(9):683–689
Avenia N, Sanguinetti A (2009) Antiobiotic prophylaxis in thyroid surgery: a preliminary multicentric Italian experience. Ann Surg Innov Res 3:10
Grogan RH, Mitmaker EJ (2012) A population-based prospective cohort study of complications after thyroidectomy in the elderly. J Clin Endocrinol Metab 97(5):1645–1653
Dionigi G, Rovera F (2006) Surgical site infections after thyroidectomy. Surg Infect 7:S1117–S1120
Culver DH, Horan TC (1991) Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 91(3B):152S–157S
Aziz RK, Kansal R (2007) Susceptibility to severe Streptococcal sepsis: use of a large set of isogenic mouse lines to study genetic and environmental factors. Genes Immun 8(5):404–415
Einhaltung ethischer Richtlinien
Interessenkonflikt. C. Bures, V. Zielinski, T. Klatte, N. Swietek, F. Kober, E. Tatzgern, R. Bobak-Wieser, E. Gschwandtner, M. Gilhofer, A. Wechsler-Fördös und M. Hermann geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Bures, C., Zielinski, V., Klatte, T. et al. Streptokokkenmediastinitis nach Thyreoidektomie. Chirurg 86, 1145–1150 (2015). https://doi.org/10.1007/s00104-014-2972-y
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DOI: https://doi.org/10.1007/s00104-014-2972-y